CONGENITAL TALIPES EQUINOVARUS -One theory that the primary problem is neuromuscular,

(CLUB FOOT) with contracture and fibrosis of the soft tissues, which
Definition tether the growth of the bones and cause the osseous
-Includes deformity of the forefoot, the hindfoot, and the deformity
ankle. -Other theory is that problem begins with the cartilaginous
-It involves the in utero mal-alignment in the anlage of the talus. Medial and plantar deviation of the
Talocancaneonavicular joint and calcaneocuboid joints talus causes subluxation of the peritalar joints and, with
and soft tissue shortening medial and posteriorly. intrauterine growth, the medial soft tissues contract,
-Term equinovarus refers to extreme plantar flexion of the leading to progressive deformity.
ankle (equinus) and medial angulation of the foot (varus). Clinical diagnosis
Abnormalities include: History
 There is adduction and supination of the Prenatal and birth history
forefoot, including both the cuneiforms and the Detailed family history of clubfoot or neuromuscular
metatarsals. disorders
 The navicular is subluxated or dislocated on the Drugs during pregnancy-Na valproate especially.
talus. Navicular is displaced medially and \Examination
dorsally. General examination to identify any other abnormalities.
 The talocalcaneonavicular joint complex is Similar deformities are seen with myelomeningocele and
subluxated medially and plantar ward. arthrogryposis
 The talus is misshapen with hypoplasia of the
neck Local examination
 Talus has medial and plantar-ward tilt with Examine the feet with the child prone, with the plantar
lateral rotation in its axis. aspect of the feet visualized and supine to evaluate
 Calcaneous plantar flexed, rotated medially, internal rotation and varus.
posterioly it’s tethered to the fibula. If the child can stand, determine if the foot is plantigrade,
 In the ankle mortise, the talus is in if the heel is bearing weight, and if it is in varus, valgus,
plantarflexion. or neutral.
 The soft tissues on the medial aspect of the foot  The ankle is in equines position
are contracted, including the joint capsules and  The foot is supinated (varus) and adducted
the muscles and tendons. -normal infant foot usually can be dorsiflexed and
Classification everted so that the foot touches the anterior tibia).
Clubfoot can be classified as  The navicular is displaced medially, as is the
(1) Postural or positional -are not true clubfeet. Are due cuboid.
to position in the uterus  Contractures on the medial plantar soft tissue
(2)Idiopathic forms –Commonest.  The calcaneus is in a position of equinus,the
Also Fixed or rigid type. Fixed or rigid clubfeet are either anterior aspect is rotated medially and the
flexible (ie, correctable without surgery) or resistant (ie, posterior aspect laterally.
require surgical release)  The heel is small and empty. The heel feels
(3)Secondary- soft to the touch. As the treatment progresses, it
Secondary to some other anomaly e.g. fills in and develops a firmer feel.
 Spina bifida myelomeningocele  The medial malleolus is difficult to palpate and
 Arthro-gryposis multiplex congenita is often in contact with the navicular.
 Tibial hemimelia.  The normal navicular-malleolar interval is
Incidence diminished.
-Clubfoot is common, with an incidence of 1 to 2 per  There are furrows in the skin on the medial
1000 live births. and plantar aspect of the foot.
-Up to 40-50% have bilateral clubfeet.  Laterally, the skin is stretched and taut. .
Sex  Muscle -Atrophy of the leg muscles, especially
Boys are affected twice as often as are girls M>F in the peroneal group, is seen in clubfeet.
Etiology  The number of fibers in the muscles is normal,
-Multifactorial inheritance combines with environmental but the fibers are smaller in size. The triceps
factors to produce the deformity. surae, tibialis posterior, flexor digitorum longus
Genetics (FDL), and flexor hallucis longus (FHL) are
-The incidence of clubfoot is 20 to 30 times higher in contracted.
first-degree relatives than in the general population.  The calf is of a smaller size and remains so
-Occurrence in- throughout life, even following successful long-
-Monozygotic twins 32% lasting correction of the feet.
- Dizygotic twins 3% The flexibility of the foot is variable. In some patients, the
- Sibling with club foot 2 to 5%. entire deformity can be easily corrected by gentle
-1 parent is also affected, with sibling also affected-25%. manipulation, but in others, the deformity is very rigid.
The flexibility of the foot at birth is important in the
prognosis.
- Clinical diagnosis of clubfoot should be accompanied by -The most common approach is to attempt to correct the
x-ray examination. forefoot varus first, properly lining up the forefoot with
-Lines can be drawn through the long axis of the talus the hind foot.
parallel to its medial border and through that of the -When, after the cast is removed, the forefoot remains in
calcaneum parallel to its lateral border; they normally proper alignment, the hind foot varus is corrected.
cross at an angle of 20-40° (Kite's angle) but in club foot -Only when the forefoot and hindfoot varus is corrected
the two lines may be almost parallel then attempt made to bring the ankle joint out of equines.
-The lateral film is taken with the foot in forced Thus, it is common to see babies with clubfoot casts held
dorsiflexion. Lines drawn through the mid-longitudinal in equinus during the early stages of treatment.
axis of the talus and the lower border of the calcaneum -In many series, casting is successful in correcting the
should meet at an angle of about 40°. Anything less than deformity in 60% or more children.
20° shows that the calcaneum cannot be tilted up into true -After correction is complete, prolonged splinting or
dorsiflexion; the foot may seem to be dorsiflexed but it bracing is required for at least a year.
may actually have 'broken' at the midtarsal level, This followed by a Denis Browne bar with attached out-
producing the so-called rocker-bottom deformity. flare shoes. Similar shoes are worn when the child begins
-Talo-1st metartasal angle should be between 0-15’ to walk, but the Denis Browne bar should be continued at
Imaging night and nap time for several more years. Correction
-X-rays are useful primarily for assessing the adequacy of achieved by age 7 years is usually permanent
correction rather than for establishing the diagnosis of -Continued observation of the clubfoot to guard against
clubfoot. recurrence is necessary well into childhood and, in some
-At birth, only the ossific nuclei of the calcaneus, talus, patients, until skeletal maturity.
and metatarsals are present. Navicular ossification does Some complications
not begin until about age 4. 1.Skin necrosis
-Therefore, radiographs of the newborn foot provide less 2.Failure of correction
information than the clinical examination. 3.Grwoth disturbance
-By 2-3 months of age, the ossification centers of the talus 4.Flat top talus
and calcaneus have elongated sufficiently to indicate their 5.Anterior ankle contracture
long axes, so that radiographs can provide helpful data 5.Rocker bottom deformity
about interosseous relationships.
-The AP film is taken with the foot 30° plantarflexed and
the tube likewise angled 30° to the perpendicular. Surgery
An anteroposterior view of a normal foot shows -Failure of nonoperative treatment is an indication for
divergence of the talus and calcaneus, the former directed surgical management of the deformity usually when the
along the first ray and the latter along the fifth ray. In patient can stand at about 9 months.
clubfoot, the talus usually points more laterally and may -Surgical correction of all clubfoot deformities is
actually appear superimposed upon the calcaneus. generally performed in one stage.
-One common option is the "Cincinnati" incision, which
MANAGEMENT extends from the navicular bone medially, around the
At birth full examination of the neonate to exclude other superior portion of the heel, to the cuboid bone laterally.
associated injuries. -During surgery, the medial posterior tibial neurovascular
Non –operative treatment bundle must be identified and protected.
-Left to itself, the true clubfoot deformity becomes more -The tendons of the posterior tibialis, flexor digitorum
rigid with time. Soft-tissue contractures and bony longus, and flexor hallucis longus, and the Achilles
deformities worsen with time. tendon are Z-lengthened.
-Therapeutic intervention should begin as early as -Then, the capsules of the talonavicular joint, subtalar
possible. (talocalcaneal) joint and posterior ankle (calcaneatibial)
-The first few weeks after birth are particularly valuable joint are released to allow repositioning of the bones of
for clubfoot treatment, for the infant retains some of the the hindfoot and midfoot.
soft-tissue laxity that resulted from maternal hormones. -The navicular is usually subluxated medially on the talus
-Daily manipulations, strappings, or casting of the foot and must be repositioned onto its normal head at the distal
should begin immediately. talus. The calcaneus is both inverted and internally rotated
-Most orthopedists treat infants with clubfoot for the first on the talus. This is corrected by manually derotating the
3 to 6 months with frequently changed serial plaster casts. subtalar joint and tilting the calcaneus back into a neutral
At each cast change, the foot is manipulated by the position.
orthopedist. The correction occurs from the -Both of these corrections are usually held in place after
manipulations; the casts are merely holding devices. reduction by inserting small Kirschner wires, which are
-Ponseti regime should begin as soon as the first day on removed after 4 weeks.
birth and should involve weekly casting but practically Cast removed at 6 weeks
changing of the serial casts 2 weekly.
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Prognosis
Pirani Club foot score
1. Posterior foot crease
2. Medial plantar crease
3. Medial foot deviation
4. Angle formed by dorsiflexion

Complications
1.Infection (rare)
2.Wound breakdown:
3. Stiffness and restricted range of motion: Early
stiffness correlates with a poor result.
4.Avascular necrosis of the talus: AVN talus
5. Persistent intoeing: This is quite common due to
insufficient external rotation correction of the subtalar
joint.
6.Growth arrest
7.Equinas ankle or valgus ankle
8.Talonavicular sublaxation
9. Gangrene due to damage of the neurovaculature.
10.Recurence

Salvage surgery-Tripple arthrodesis